Home birth - is it for you?

Sarah Tennant spells out why home birth is considered safer, more comfortable and less painful for many women than hospital births.

There's no denying it, planning a home birth is risky. Not for your baby - for your reputation. Currently about 5% of Kiwi women give birth at home, and it's a fair bet most of them have had to deal with a disapproving female relative reminding them, "If I hadn't been in the hospital when I had my first, I'd have died."

The mother of a friend of mine was so horrified at the thought of her daughter planning a home birth she rang the midwife and proceeded to bawl her out.

A relative of mine, after unsuccessfully debating birth safety statistics with me for some time, eventually resorted to, "But who will wash the sheets?" (Astoundingly, this failed to change my mind. Sadly, I developed pre-eclampsia in late pregnancy and had to be induced at the hospital after all. I suspect the said relative was relieved.)

Stereotypes and misconceptions of home births and midwives abound. Many people seem to believe midwives turn up to a birth with no equipment save a bag of dusty herbs, happily allowing a mother to haemorrhage by candlelight while everyone listens to whale song. Home birth is seen as the selfish choice - made by mothers who prioritise an idyllic birth over their babies' health.

In fairness, I can see why people think this. Everyone has a few juicy labour horror stories and on the face of it, more medical equipment and expertise should surely be safer, rather than less.

The problem is, the statistics don't support that reasoning. Several studies in New Zealand, and dozens overseas, have confirmed that for low-risk women (single, vertex babies, no maternal conditions such as pre-eclampsia and so on), a planned, attended home birth - as distinguished, importantly, from unassisted childbirth or an oops! baby born in the car - involves no higher risk of the mother or baby dying than a comparable low-risk hospital birth. In fact, in a sense home-birthing mothers and babies are safer - the same studies show that home birthers are less likely to end up with Caesarean sections, episiotomies, epidurals or analgesic pain relief, and babies with low Apgar scores.

As a result, home birth in New Zealand is widely accepted by the medical community. Home births are fully funded by the government, and transferring in the case of an emergency is usually efficient. Even my government "pregnancy week by week" guide, which I tend to find depressingly alarmist, states unequivocally that home birth is a safe option even for first-time mothers. In other words: home birth works. But how?

There's no place like home Ironically, the answer may lie largely in the very factor anti-home birthers find wishy-washy: the birth experience. No, not the candles or the music but the simple fact that in a home birth, a woman labours on her own turf - in a comfortable, familiar environment where she is in control.

Think of the average mammal giving birth. Labours are generally quick, with pain at manageable levels; but only if the animal is given privacy, a sense of safety, and preferably a nest of her own in which to birth. In the wild, animals can "freeze" labour for days if they sense birthing is not safe, perhaps due to a predator. Even pets and farm animals have an annoying habit of not birthing until humans have left them alone and gone to bed.

Human mammals are no different. Birthing efficiently requires lots of the hormone oxytocin, usually released during safe, loving experiences. Stress releases adrenalin, which counteracts the oxytocin, causing muscles to tense - the last thing women need in labour.

How does this relate to hospital birth? Obstetrician Michael Rosenthal perhaps put it best when he stated, "The first intervention in birth that a healthy woman takes is when she walks out the front door of her home in labour." When the mammal leaves her familiar nest and enters a place of unknown authority figures, bright lights, strange smells, unfamiliar and sometimes painful procedures and restricted movements, she is doing something unnatural.

Think about your experiences in hospital. I've had a less exciting medical history than some but our hospital is full of not-so-cosy associations: visiting a friend dying of Crohn's disease, seeing my mother on a bed with a row of Tim Burton-esque stitches across her throat and a traumatic birth of my own. Intellectually I'm grateful the hospital existed in all those situations but it hardly screams, "This is a safe and secure environment in which to give birth."

The physiological result of this stress is profound: with adrenalin at war with oxytocin, muscles tensed, labour becomes painful and inefficient. Famous midwife Ina May Gaskin observed that following a stressful event - including simply entering a hospital - labouring women could actually experience "reverse dilation", their cervix shrinking from 6cm to 3cm out of pure nerves. After considerable research, Gaskin developed the theory of "sphincter law".

Sphincter law Sphincter law states that the various interrelated sphincters of the body - in the throat, anus, cervix and so on - tend to tighten in the presence of stress. If you've ever felt your throat close up before speaking in public or been too shy to perform certain bodily functions in any bathroom except your own, you've been the victim of sphincter law. As birth ultimately relies on the dilation and relaxation of sphincters, a relaxed environment is almost a necessity.

This line of reasoning may explain why medical statistics consistently support home birth. When labour is compromised by stress it can lead to all manner of interventions - epidurals, analgesia, constant foetal monitoring, artificial rupture of membranes, even a diagnosis of "failure to progress" and a C-section. All these procedures have risks for mother and baby. Where they can safely be avoided due to a stress-free labour, the chances of a disaster - cord prolapse, foetal distress, respiratory problems in the newborn and failure to establish breastfeeding - drop considerably.

Obviously, home-birthing does not guarantee a stress-free labour; and some women may feel safer in a hospital, meaning sphincter law could backfire if they were pressured to stay home. However, there are some solid reasons why a home birth tends to be less stressful.

For one thing, women are used to their homes being multi-functional. One of the best ways to deal with early labour is to ignore it; in a hospital a woman has little to focus on except her contractions. At home, a woman can endeavour to pretend labour isn't happening while she watches a movie, folds laundry or tidies the baby's room between contractions. Some home-birthing women actually plan a project for early labour, such as baking the baby a birthday cake or kneading bread.

At home, being familiar with her space and in control of it, a woman is more likely to use any available resource for comfort and pain relief. In hospital rooms the bed dominates the set-up. At home, a woman feels no inhibitions about using the couch, stairs, toilet, shower or kitchen bench for support and comfort. Few women have the chutzpah to crawl around on a hospital floor, which will be cold and unpleasant anyway, but at home, anything goes. Interestingly, French childbirth guru Michel Odent had the rooms at his birthing centre redesigned after he observed women typically abandoned the designated birth space in favour of a smaller, more private space such as a bathroom or walk-in-wardrobe.

The proof of all this does not just lie in home birth's reduced rate of interventions, but in women's perceptions of the experience. A 1988 study catchily titled "Home Birth and Hospital Deliveries: A Comparison of the Perceived Painfulness of Parturition" found that hospital-birthing women said childbirth was more painful than home-birthing women did.

Birthing centres Statistically, birthing centre births are as safe for low-risk women as home and hospital births, with intervention rates similar to home births. I've also found relatives are much more accepting of birthing centres, despite them containing no more medical equipment or expertise than a midwife at a home birth!

What's the upshot of all this research? The biology of labour means home birth is not simply hospital birth minus the facilities for a C-section; and hospital birth isn't "home birth plus". The two modes of birth are fundamentally different and affect the mind and body in different ways. So if you're planning a home birth, the next time someone sneers at you for wanting a "pretty birth experience", beam rapturously and agree. Firstly, a familiar, relaxing environment doesn't pit your interests against the baby's - it's good for both of you. Secondly, it'll annoy the heck out of your naysayer. And that's psychologically beneficial.

Home birth research A study of planned home births in New Zealand between 1973 and 1993 concluded that the risk of perinatal mortality was comparable to low-risk women who gave birth at National Women's Hospital in Auckland. (NZ Medical Journal, 1997 Mar 28; 110(1040):87-9.)

A New Zealand study of 16,400 low-risk women giving birth during 2006 and 2007 found that women who planned to birth at home were at "less risk of augmentation of labour, artificial rupture of membranes, pharmacological pain management, episiotomy and perineal trauma than those planning to give birth in primary units".

A 2009 thesis comparing first-time Kiwi mothers concluded, "Despite being cared for by the same midwives, women in the hospital-birth group were more likely to use pharmacological methods of pain management, experienced more interventions (ARM, vaginal examinations, IV hydration, active third stage management and electronic foetal monitoring) and achieved spontaneous vaginal birth less often than the women in the home birth group."

Overseas, a Danish meta-analysis of six studies spanning 24,000 births concluded that home birth had comparable mortality rates with hospital births and a reduced incidence of morbidity - particularly low Apgar scores and perineal tears. A US study of over 5400 women had similar findings, also noting a high rate of breastfeeding success among the home-birthing mothers.

Sarah Tennant is a mum and freelance writer in Hamilton. She gave birth to her second child, Miles, in June.